Provider Demographics
NPI:1740598093
Name:EDMONDS, ANN DIANESE LEE
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:DIANESE LEE
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 16TH ST NW
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:VA
Mailing Address - Zip Code:24301-2433
Mailing Address - Country:US
Mailing Address - Phone:540-392-3774
Mailing Address - Fax:
Practice Address - Street 1:131 16TH ST NW
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301-2433
Practice Address - Country:US
Practice Address - Phone:540-392-3774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2076700225200000X
VA2306602865225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant